Clinical Quality

Job Title: Clinical Quality & Improvement Officer

Program/Dept.: Administration

Classification: Regular, Part-Time, Exempt

Salary Range: $95, $150,000.00/Annually

Reports to: President & CEO

Location: 4879 E. Cesar Chavez Blvd, Fresno, CA 93727

Date: October 29, 2025

1. AGENCY

The Fresno Center (TFC) is a non-profit organization that was established in the past 30+ years, serving the community of Fresno County. TFC offers 20 different support services that include mental health, wellness, and healing, from immigration to education advocacy to clinical behavioral services to holistic wellness services. TFC is the one-stop shop that promotes cross-cultural understanding and cultural preservation. Eight of our 20+ programs focus on mental health services (Horticultural Therapeutic Community Centers Program, Living Well Center, Holistic Wellness Program, California Reducing Disparity Project, Central Valley Regional Center Latino and Southeast Asian Navigator Program, and Kaiser Community Benefits Program). Our motto is to "Inspire, Empower, and Cultivate". Our commitment is to equip staff with the best training and practices to develop and maintain client loyalty and be the employer of choice in the Central Valley.

The Fresno Center's Mission Statement: To assist individuals in becoming self-sufficient, self-fulfilled and productive members of the community while fostering cultural preservation and promoting cross cultural understanding.

The Fresno Center's Vision: The Fresno Center will be a champion for positive change through empowerment, education, and collaboration.

2. THE PROGRAM

The Clinical Quality & Improvement Officer (CQIO) reports directly to and works in close partnership with the President and CEO, providing executive oversight for quality assurance, regulatory compliance, and performance improvement across all clinical programs. This role ensures alignment between The Fresno Center's mission and operational excellence, maintaining compliance with county, state, and federal standards including Title 22, DHCS, HRSA, and CalAIM. The CQIO develops and implements systems to improve the accuracy of clinical documentation, strengthen Medi-Cal/Medicare billing integrity, and uphold the highest standards of care, safety, and accountability across programs such as CalAIM Enhanced Care Management (ECM), the Living Well Clinic (LWC), Adult Day Health Care (ADHC) services, and other health services and initiatives.

The position is contingent upon continued funding. The Fresno Center will not be responsible in any manner for terminations which are due to the defunding of Federal or State Contracts/Grants. The Fresno Center is at-will and may be terminated by you or the company at any time regardless of the end date of the Federal or State Contracts/Grants.

3. POSITION SUMMARY

Working collaboratively with the CEO, program directors, and multidisciplinary teams, the CQIO leads data-driven initiatives to enhance quality, compliance, and operational performance. This includes conducting audits, developing corrective action plans, training staff, and optimizing EHR workflows to support documentation accuracy and regulatory readiness. The CQIO prepares and presents quality and compliance reports to executive leadership, drives continuous quality improvement (CQI) projects, and fosters a culture of excellence that improves patient outcomes, staff performance, and organizational sustainability.

Responsibilities include conducting cost-benefit analyses, overseeing financial compliance and utilization reviews, and integrating quality and fiscal accountability into daily operations. The Officer develops and monitors key performance indicators (KPIs) that link quality outcomes to financial performance, supports continuous quality improvement (CQI) processes, and promotes a culture of fiscal responsibility and operational excellence across all clinical programs.

4. JOB DUTIES & RESPONSIBILITIES

Quality Assurance & Compliance

4.1. Develop, implement, and monitor the organization's Quality Assurance and Performance Improvement (QAPI) Plan in compliance with Title 22, DHCS, DBH, MHSA, BHCIP, and HRSA requirements.

4.2. Conduct internal audits of clinical documentation, treatment plans, and service delivery to ensure compliance with managed-care and health requirements and standards.

4.3. Monitor and track performance metrics, adverse events, and incident reports; lead root cause analyses and implement corrective action plans.

4.4. Maintain readiness for all external audits, training, reviews, and accreditation processes.

4.5. Ensure compliance with all state and federal laws governing patient privacy, safety, and care standards (e.g., HIPAA, OSHA, CMS).

Performance Improvement

4.6. Lead data collection and analysis to identify trends, performance gaps, and opportunities for process improvement.

4.7. Develop and implement continuous improvement projects to enhance patient care quality, access, and efficiency.

4.8. Collaborate with program directors and department leads to integrate performance metrics into daily operations.

4.9. Design, facilitate, and evaluate clinical training programs to strengthen documentation accuracy, treatment planning, and outcome measurement.

Clinical Oversight & Support

4.10. Provide leadership and consultation to clinical managers and multidisciplinary teams to maintain best practices and adherence to standards of care.

4.11. Ensure policies and procedures are up to date and align with evolving regulatory and payer requirements.

4.12. Participate in clinical risk management and incident review committees.

4.13. Partner with IT/EHR/Finance & Planning Office teams to optimize clinical documentation workflows and data integrity.

Reporting & Communication

4.14. Prepare and present weekly, monthly, and quarterly quality and compliance reports to executive leadership and governing boards.

4.15. Maintain effective communication channels between administration, clinical staff, and external oversight agencies.

4.16. Support program evaluation efforts for grants, contracts, and funding renewals by providing data analysis and outcome summaries.

Clinical Fiscal duties

4.17. Partner with the President/CEO to align quality, compliance, and financial performance across all clinical programs.

4.18. Lead cost-effective quality improvement initiatives that enhance care, efficiency, and regulatory compliance.

4.19. Analyze program costs, utilization, and performance data to guide strategic and operational decisions.

4.20. Oversee documentation accuracy and billing integrity to ensure compliance and prevent revenue loss and saving costs and reduce unnecessary spending.

4.21. Develop and track KPIs connecting clinical quality to financial sustainability.

4.22. Promote a culture of accountability, efficiency, and continuous improvement across teams.

5. MINIMUM QUALIFICATIONS:

5.1 Must have transportation

5.2 Clean DMV record and valid vehicle insurance

5.3 Must pass background check/Live Scan and Drug Test

5.4 Commitment to the mission and values of the agency

5.5 Committed to community building and development

6. COMPENTENCY:

Skills & Competencies

6.1. Accountable for meeting commitments and taking ownership of tasks and deadlines.

6.2. Growth mindset. Objective-driven. Mission driven. Executive level business communicator.

6.3. Exhibits strong business acumen with the ability to align operational decisions with organizational goals and financial sustainability.

6.4. Financially and fiscally skilled to monitor costs and financial sustainable services.

6.5. Experience with Medicare, Medical, SmartCare, Simple Practice, and Microsoft Office Suite.

6.6. Strong analytical and problem-solving skills with the ability to identify documentation and workflow gaps.

6.7. Excellent training, facilitation, and interpersonal communication skills.

6.8. Highly organized, detail-oriented, and adaptable to changing regulations.

6.9. Bilingual in Hmong preferred.

6.10. Strong analytical and problem-solving skills with a data-driven approach.

6.11. In-depth understanding of healthcare quality metrics, outcome measurement, and compliance frameworks.

6.12. Excellent communication, training, and presentation abilities.

6.13. Ability to lead cross-functional teams and manage multiple projects simultaneously.

6.14. Proficiency with EHR systems (e.g., SmartCare, Epic, Simple Practice) and Microsoft Office Suite.

6.15. Commitment to equity, inclusion, and culturally responsive care.

Compensation & Benefits

6.16. Competitive salary commensurate with experience ($95,000 – $150,000 annually).

6.17. Comprehensive benefits package including medical, dental, vision, retirement, and paid leave.

6.18. Professional development and continuing education opportunities.

7. PERSONAL QUALITIES

7.1. Accountable

7.2. Diligent and organized.

7.3. Ethical and loyal

7.4. Punctual

7.5. Flexible

7.6. Problem-solver

7.7. Creative

7.8. Honest

8. WORK ENVIRONMENT:

8.1. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

8.2. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

9. TYPICAL WORKING CONDITIONS:

9.1. The office setting is a normal environment.

9.2. Occasionally work during early morning, evening, or weekend.

9.3. May be subject to temperature variances in the office.

9.4. The noise level in the work environment is usually moderate but may become excessively loud with the increased patient flow during a busy day.

10. TYPICAL PHYSICAL DEMANDS.

10.1. Requires sitting, standing, or walking for up to eight hours a day.

10.2. Some bending, stretching, or reaching may be necessary.

10.3. Lifting to 40 pounds may be required on occasion.

10.4. Vision must be correctable to 20/20

10.5. Hearing must be in the normal range for telephone contact.

11. POSITION TYPE AND EXPECTED HOURS OF WORK:

11.1. Part-time, typical work hours are between 8:00 am to 5:00 pm, Monday to Friday. Position provides flexibility which may include some shifts remotely.

11.2. Evenings and weekends as needed.

12. TRAVEL:

12.1. Travel time is expected for the position. Travel time includes travel to meetings, off-site training, or between job sites, as needed, locally.

12.2. Individuals may also be expected to use their own vehicle to travel and with mileage reimbursement.

12.3. A company car may be used when transporting a client to and from his or her placement, or field activities.

13. REQUIRED EDUCATION AND EXPERIENCE:

13.1. Bachelor's or Master's degree in Nursing, Public Health, Healthcare Administration, Behavioral Health, or related field.

13.2. Minimum 10 years, plus of clinical experience in healthcare quality improvement, compliance, or clinical operations management.

13.3. Knowledge of California Title 22, CalAIM, DBH, and DHCS documentation and billing standards.

13.4. Has Professional Affiliations:

· Association of Clinical Documentation Integrity Specialists (ACDIS)

· American Health Information Management Association (AHIMA)

· California Health Information Association (CHIA)

· Oncology Nurses Society (ONS)

14. PREFERRED EDUCATION AND EXPERIENCE:

14.1. Doctor of Nursing Practice (DNP), preferred

14.2. Master of Science in Nursing (MSN), Family Nurse Practitioner, preferred

14.3. Associate of Science in Health Information Technology, preferred

14.4. Bachelor of Science in Nursing (BSN), preferred

14.5. Licensed RN, LCSW, LMFT, LPCC, or other qualified clinical license in California.

14.6. Experience in an FQHC, Adult Day Health Care (ADHC), and behavioral health outpatient setting.

14.7. Familiarity with HRSA, Joint Commission, and QAPI processes.

15. BENEFITS:

15.1. Medical, vision, and dental coverage at 50% cost.

15.2. Life insurance coverage at annual salary.

15.3. Pro-rated Sick leave, per personnel policy.

k retirement plan, after completion of 90 days of employment; potential 3% match.

15.5. Pro-rated vacation, per personnel policy

15.6. Holidays per personnel policy

16. Affirmative action plan/Equal employment opportunity (AAP/EEO):

It is the policy of The Fresno Center to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law. This policy relates to all phases of employment, including, but not limited to, recruiting, employment, placement, promotion, transfer, demotion, reduction of workforce and termination, rates of pay or other forms of compensation, selection for training, the use of all facilities, and participation in all company-sponsored employee activities. Provisions in applicable laws providing for bona fide occupational qualifications, business necessity or age limitations will be adhered to by the company where appropriate.

As part of the company's equal employment opportunity policy, The Fresno Center will also take affirmative action as called for by applicable laws and Executive Orders to ensure that minority group individuals, females, disabled veterans, recently separated veterans, other protected veterans, Armed Forces service medal veterans, and qualified disabled persons are introduced into our workforce and considered for promotional opportunities.

17. Acknowledgment

I acknowledge that I have read and understand the above job description, responsibilities, and standards of the position. I understand that the job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice. I am responsible for reading this job description and complying with all job duties, requirements, and responsibilities contained herein, and any subsequent revisions.

I understand the position is contingent upon continued funding and the (The Fresno Center) will not be responsible in any manner for terminations which are due to defunding of Federal or State Contracts. I understand that I am an at-will employee and can be terminated at any time with or without cause.

Job Type: Part-time

Pay: $95, $150,000.00 per year

Work Location: In person